Preoperative Nursing Managements Fall Semester 2015 Amal Bsoul

Perioperative Nursing Period of time that constitutes the surgical experience. Includes three phases: Preoperative phase: the period of time from the decision for surgery until the patient is transferred into the operating room. Intraoperative phase: the period of time from when the patient is transferred to the operating room to the admission to postanesthesia care unit (PACU). Postoperative phase: the period of time that begins with admission to the PACU and ends with follow-up evaluation in the clinical setting or at home.

Surgical Classifications According to the reason: - Diagnostic ( e.g biopsy) - Curative ( e.g excision of inflamed appendix) - Reparative (e.g multiple wound repair) - Reconstructive or Cosmetic (e.g face lift) - Palliative (e.g insertion of gastrostomy tube)

According to the degree of Urgency: - Emergent: without delay, lifethretining ( e.g sever bleeding, gun shot) - Urgent: within 24 – 30 hr’s (e.g acute gallbladder infection) - Required: within few weeks or months, but not immediately necessary - (e.g cataracts) - Elective: (e.g repair a scar) - Optional: personal preferences, is not needed to preserve life or function, (e.g cosmetic surgery)

Preparation for Surgery: preoperative assessments Informed Consent: the patient autonomous decision about whether to undergo a surgical procedure, based on the nature of the condition, the treatment options, and the risks and benefits involved. - It is a voluntary and written statement from the patient. - It is necessary before nonemergent surgery. - The purpose : - to protect the patient from unsanctioned (unwanted) surgery - to protect the surgeon from claims of an unauthorized operation.

B efore signing, the surgeon provide a clear and simple explanation of B enefits A lternatives P ossible risks C omplications D isfigurement D isability W hat to expect early and late postoperative periods.

P atient must be L egal age M entally capable. F amily member signs, when the patient is M inor U nconscious I ncompetent

Continue - The nurse should notify the physician if the pt need any additional information. - The nurse should ensure that the consent signed before administration of premedecation. - The pt should not be forced or urged to give informed consent. - Signed consent place in patient’s chart and accompanies him to the OR. When the consent form is necessary? Who will signed the consent?

Initial preoperative assessment which include: Health HX. Physical Examination. Ensure that necessary test (lab work) have been or will be performed

Assessment of health factors (risk factors for surgical complications) Nutritional and fluid status: - Hypovolemia, dehydration, electrolyte imbalance - Obesity - Wt loss - Malnutrition - Metabolic abnormalities Note: review table 18-2 p 487. (important nutrient for wound healing)

Drug or Alcohol use: - Assess for drug abuse and alcohol intake Respiratory Status: - Respiratory infection - Underlying respiratory disease (asthma, COPD) - HIV - Smoking (pt asked to stop smoking at least 24hr’s before surgery).

Cardiovascular status: - Presence of HTN - CAD or previous MI - Cardiac Failure - Dysrhythmias - Prosthetic heart valve Hepatic and Renal Function: - Liver cirrhosis - Hepatitis - Nephritis - Renal insufficiency or renal failure

Endocrine Function: - DM - Adrenal Insufficiency - Thyroid Disorder Immune Function: - Is their any sensitivity to medications, reactions to Bld transfusion, contrast agents, Latex, food products. - Assess if the pt taking corticosteroid, chemotherapy or radiotherapy, have kidney transplantation.

Previous Medication use: - Assess use of OTC preparation as aspirin - Herbal agents Note: Review table 18-3 p 490 (Medication that can cause particular concerns) Psychosocial Factors:- - Assess for Anxiety & Fear Spiritual & Cultural Beliefs:- - Assess the beliefs the pt holds about illness, and health care providers

Nursing Diagnoses for pt preoperatively: Knowledge Deficit regarding (surgical procedure, or self care management post op) R/T first experience AMB S&O data. Anxiety R/T fear of (dying, anesthesia, pain) AMB S&O data. Pain (acute) R/T disease process AMB S&O data.

General pre operative intervention

Preoperative Teaching Teaching should be include the description of the procedure and explanation of the sensation the pt will experiences. The ideal time for teaching not on the day of surgery, but during preadmission visit. Written Instruction should given to patient

Preoperative teaching: - Preoperative experience & surgical procedure - Preoperative medication - Deep breathing Exercise - Coughing exercise - - mobility and ambulation. Rational: - To promote pt relaxation, and increase pt knowledge - Help pt to attain higher degree of relaxation. - To promote optimal lung expansion & help pt relax - To mobilize secretion & prevent lung complications - - to improve circulation, promote respiratory function.

Preoperative teaching: - Teach pt to change position frequently (Q4hr’s) - Ask pt to demonstrate R.O.M of the extremities. - Assess pt level of pain - Teach pt pain management skills - Informed the pt that his pain will be under control post op - Give analgesic as needed. Rational: - To improve circulation - To prevent venous stasis - To promote greater pain relief during early postop period. - To help pt gain control and help in decreasing pain

Preoperative teaching: - Teach pt Coping strategies: * Imaginary : ask pt to concentrate on pleasant experience. * Distraction : ask pt to think of an enjoyable story. * Optimistic self recitation: teach pt to think positively - Informing the pt about the possible need for special equipment - Apply music therapy - Let the pt know that family member will be able to visit post op Rational: - To relive tension, overcoming anxiety, decreasing fear, achieving relaxation. - Help decrease anxiety post op - To reduce anxiety - To help decrease pt fear.

Diaphragmatic Breathing and Splinting When Coughing Breathing exercise repeated Q15mint with a rest period after each 5 group Ask pt to demonstrate this technique 2 times\day

Leg Exercises and Foot Exercises Leg exercise done 5 times for each leg then perform for the other leg Foot exercise repeated 5 times.

General Preoperative Nursing Interventions Patient safety (protect from injury) is a primary concern. NPO (overnight), in some recommendation (Brady et al, 2004) advice adult to fast for 8hr’s after eating fatty food, and 4hr’s after ingesting milk products, and most pt currently allowed to take clear liquid up to 2hr’s before elective procedure.(to prevent aspiration). Bowel prep: for pt underwent abdominal or pelvic surgery, done by using cleansing enema or laxative at the evening before surgery skin prep: electric clippers used immediately before the operation.

Immediate preoperative preparation Wear pt hospital gown, keep untied and open in the back Remove hairpins, and cover the head completely with paper cap. Inspect the mouth, remove any denture Remove jewelry, wedding rings Remove any makeup or nail polish Ask pt to void immediately before going to OR Administer premedecation Complete preoperative checklist (figure18-3, p 497) The chart and the checklist accompanies pt to the OR and the consent formed also attached

Special situation: For elderly pt: - They have less physiologic reserve, so nurse must be alert to maintain safe environment - Provide protective measures - Precaution are taken when moving elderly person. - Supply pt with light cotton blanket when moved to OR - Incorporate pain management information, and communication skills to help elderly pt to obtain greater post op pain relief.

Obese pt: - They need special attention on the wound area - Careful assessment to the respiratory function, and other complications. Pt with disabilities: - They need appropriate assistive device - Modification in preoperative teaching - Additional assistance with and attention to positioning or transferring